OSHA Training Institute Education Centers Program OSHA Outreach ...

OSHA Training Institute Education Centers ProgramOSHA Outreach Trainer CoursePREREQUISITE VERIFICATION FORMRead instructions before completing this form.Submit completed forms to:It is the responsibility of the applicant to ensure all course prerequisites have been met prior to enrolling in the course. Please submit copies of thiscompleted and signed form and all necessary documentation for prerequisite courses to the authorized OTI Education Center listed above PRIORTO ENROLLING IN THE COURSE. Registration is not permitted without approval.OSHA Trainer Course Prerequisites OSHA #500 Construction - OSHA #510 Occupational Safety and Health Standards for the Construction Industry course and five years of constructionsafety experience. A college degree in occupational safety and health, a Certified Safety Professional (CSP), Certified Industrial Hygienist (CIH),Certified Safety & Health Technician (CSHT) or Certified Safety & Health Manager (CSHM) designation in the applicable training area may besubstituted for two years of experience with proper documentation. OSHA #501 General Industry - OSHA #511 Occupational Safety and Health Standards for General Industry course and five years of general industrysafety experience. A college degree in occupational safety and health, a Certified Safety Professional (CSP), Certified Industrial Hygienist (CIH),Occupational Safety & Health Technician (OSHT) or Certified Safety & Health Manager (CSHM) designation in the applicable training area maybe substituted for two years of experience with proper documentation. OSHA #5400 Maritime – OSHA #5410 Occupational Safety and Health Standards for the Maritime Industry Course and three years of maritime safetyexperience. Additional requirements include two years of occupational safety and health experience (with a broad focus) in any industry; acollege degree in occupational safety and health, from an accredited college or university; an Associate Safety Professional (ASP), Certified SafetyProfessional (CSP), Certified Industrial Hygienist (CIH), Certified Marine Chemist (CMC), or Certified Safety & Health Manager (CSHM)designation. OSHA #5600 Disaster Site Worker – OSHA #500 Trainer Course in Occupational Safety and Health for the Construction Industry or OSHA #501 TrainerCourse in Occupational Safety and Health for General Industry, three years of safety training experience and completion of the 40-hour HAZWOPERcourse. If the expiration date on the trainer authorization card is less than ten (10) years old, proper documentation must be provided prior to beingallowed to register for the trainer course without having to take the corresponding OSHA prerequisite course. Documentation must be providedto the OTI Education Center in order to verify the OSHA prerequisite course has been successfully completed including, at a minimum, the mostrecent applicable trainer authorization card. If proper documentation is not available, completion of the OSHA prerequisite course is required. In the event a previously authorized trainer wishes to register for a trainer course but the expiration date on the trainer authorization card is morethan ten (10) years old, all OTI Education Centers are required to enforce the current course prerequisites, which include completion of the OSHAprerequisite course. Outreach trainers are required to attend an Outreach Trainer Update course at least once every four years to maintain their trainer status.Applicant Information – Please type or print1. Applicant Name: 2. Title:3. Company: 4. E-Mail:5. Applicant AddressCompany:Address:City: State: ZIP:Phone No.: ( ) Fax No. ( )6. I am applying for the OSHA #500 OSHA #501 OSHA #5400 OSHA #5600NOTE: This form is not intended for use by trainers taking an update course. An authorized trainer who is interested in attending an update coursemust submit an authentic copy of their trainer card to the OTI Education Center in advance of enrollment in the update course.7. Course Dates: 8. Course Location:9. I have completed the following prerequisite course(s) (Please attach a copy of your course completion card or certificate for each applicablecourse):Construction General Industry Maritime Disaster Site WorkerOSHA #500 OSHA #501 OSHA #5400 OSHA #500 or #501OSHA #502 OSHA #503 OSHA #5402 OSHA #5600OSHA #510 OSHA #511 OSHA #5410 OSHA #5602Page 1 of 7OSHA Form 4-50-10April 2012

OSHA Training Institute Education Centers ProgramOSHA Outreach Trainer CoursePREREQUISITE VERIFICATION FORMRead instructions before completing this form.List Work Experience with Most Recent Employer First10. Employer Name: 11. Contact Person:12. Contact Person’s Phone Number: 13. Contact Person’s Email Address:14. Employer Address:Company:Address:City: State: ZIP:15. Start Date of Employment: 16. End Date of Employment:17. Overall Job Duties in this Position:18. Describe Safety Activities in This Position:19. What Percentage of This Position is Safety Related?Office Use OnlyLength of Experience in this Job:List Work Experience with Next Most Recent Employer20. Employer Name: 21. Contact Person:22. Contact Person’s Phone Number: 23. Contact Person’s Email Address:24. Employer AddressCompany:Address:City: State: ZIP:25. Start Date of Employment: 26. End Date of Employment:27. Overall Job Duties in this Position:28. Describe Safety Activities in This Position:29. What Percentage of This Position is Safety Related?Office Use OnlyLength of Experience in this Job:Page 2 of 7OSHA Form 4-50-10April 2012

OSHA Training Institute Education Centers ProgramOSHA Outreach Trainer CoursePREREQUISITE VERIFICATION FORMRead instructions before completing this form.List Work Experience with Next Most Recent Employer30. Employer Name: 31. Contact Person:32. Contact Person’s Phone Number: 33. Contact Person’s Email Address:34. Employer AddressCompany:Address:City: State: ZIP:35. Start Date of Employment: 36. End Date of Employment:37. Overall Job Duties in this Position:38. Describe Safety Activities in This Position:39. What Percentage of This Position is Safety Related?Office Use OnlyLength of Experience in this Job:Complete This Section To Substitute Education or Professional Certification for 2 Years Work Experience40a. COLLEGE DEGREE – PROOF REQUIRED 40b. PROFESSIONAL CERTIFICATION – PROOF REQUIREDI have a degree in occupational safety and health from an accreditedcollege or universityI am a Certified Safety Professional (CSP)Name of College or University from which degree was acquiredDate of GraduationName of DegreeI am a Certified Safety & Health Technician (CSHT) (constructionapplicants only)I am a Certified Industrial Hygienist (CIH)I am a Certified Safety & Health Manager (CSHM)I am an Occupational Safety and Health Technician (OHST)(general industry applicants only)I have the associate safety professional certification (ASP)(maritime applicants only)I am a Certified Marine Chemist (CMC) (maritime applicants only)I have attached the required copy of my transcripts (Required).Unofficial transcript is acceptable.I have attached the required copy of my current professionalcertification as a CSP, CIH, CSHT or CSHM (Required).41. Statement of CertificationThe information I have included herein and submitted to the OTI Education Center (or its designee) is true and accurate.Applicant Signature:Date:Page 3 of 7OSHA Form 4-50-10April 2012

OSHA Training Institute Education Centers ProgramOSHA Outreach Trainer CoursePREREQUISITE VERIFICATION FORMRead instructions before completing this form.THIS PAGE IS USED FOR INTERNAL PURPOSES ONLYOFFICE USE ONLYCheck One:ApprovedNot ApprovedApproving Authority SignaturePlease print nameIf not approved, please indicate reasonApplicant did not take the prerequisite courseApplicant did not meet the required years of experienceApplicant did not submit proof of applicable certificationOther (Please explain)Applicant’s trainer card expired over 10 years agoApplicant did not include transcriptsApplicant did not sign formPage 4 of 7OSHA Form 4-50-10April 2012

OSHA Training Institute Education Centers ProgramOSHA Outreach Trainer CoursePREREQUISITE VERIFICATION FORMRead instructions before completing this form.Instructions for OSHA Outreach Trainer Course ApplicantsIt is the responsibility of the applicant to ensure all course prerequisites have been met prior to enrolling in the course. Pleasesubmit copies of this completed and signed form and all necessary documentation for prerequisite courses to (Name & Contactinfo for approving OTI Education Center) PRIOR TO ENROLLING IN THE COURSE. Registration is not permitted withoutapproval.OSHA Course Prerequisites Construction - OSHA #510 Occupational Safety and Health Standards for the Construction Industry course and five years ofconstruction safety experience. A college degree in occupational safety and health, a Certified Safety Professional (CSP),Certified Industrial Hygienist (CIH), Certified Safety & Health Technician (CSHT) or Certified Safety & Health Manager(CSHM) designation in the applicable training area may be substituted for two years of experience with properdocumentation. General Industry - OSHA #511 Occupational Safety and Health Standards for General Industry course and five years ofgeneral industry safety experience. A college degree in occupational safety and health, a Certified Safety Professional(CSP), Certified Industrial Hygienist (CIH), Occupational Safety & Health Technician (OSHT) or Certified Safety &Health Manager (CSHM) designation in the applicable training area may be substituted for two years of experience withproper documentation. Maritime – OSHA #5410 Occupational Safety and Health Standards for the Maritime Industry Course and three years ofmaritime safety experience. Additional requirements include two years of occupational safety and health experience(with a broad focus) in any industry; a college degree in occupational safety and health from an accredited college oruniversity; an Associate Safety Professional (ASP), Certified Safety Professional (CSP), Certified Industrial Hygienist(CIH), Certified Marine Chemist (CMC), or Certified Safety & Health Manager (CSHM) designation. Disaster Site Worker – OSHA #500 Trainer Course in Occupational Safety and Health for the Construction Industry or OSHA#501 Trainer Course in Occupational Safety and Health for General Industry, three years of safety training experience andcompletion of the 40-hour HAZWOPER course. If the expiration date on the trainer card is less than ten (10) years old, proper documentation must be provided prior tobeing allowed to register for the trainer course without having to take the corresponding OSHA prerequisitecourse. Documentation must be provided to the OTI Education Center in order to verify the OSHA prerequisite coursehas been successfully completed including, at a minimum, the most recent applicable trainer card. If properdocumentation is not available, completion of the OSHA prerequisite course is required. In the event a previously authorized trainer wishes to register for a trainer course but the expiration date on the trainercourse card is more than ten (10) years old, all OTI Education Centers are required to enforce the current courseprerequisites, which include completion of the OSHA prerequisite course. Outreach trainers are required to attend an Outreach Trainer Update course at least once every four years to maintaintheir trainer status.Item 1Item 2Applicant NameList your full, legal name.TitleList your current job title. If you are currentlynot working, please leave this field blank.Item 4Item 5E-MailList a current, working email where you canbe contacted.Applicant AddressProvide a current, work address, phone andfax number where you can be contacted.Item 3CompanyList your current employer. If you arecurrently not working, please leave this fieldblank.Item 6CourseCheck the box indicating which course youare interested in attending.Page 5 of 7OSHA Form 4-50-10April 2012

OSHA Training Institute Education Centers ProgramOSHA Outreach Trainer CoursePREREQUISITE VERIFICATION FORMRead instructions before completing this form.Item 7Item 8Item 9Course DatesList dates you wish to take course from theOTI Education Center’s course schedule. Ifyou are unsure, leave this field blank.Course LocationList the location of the specific course inwhich you would like to enroll. If you areunsure, leave this field blank.Prerequisite CourseCheck the box which corresponds to theapplicable prerequisite OSHA course(s) youhave completed: For the OSHA #500, the prerequisitecourse(s) are the OSHA #510 orOSHA #500 course, for the OSHA#502, the prerequisites are the OSHA#500 or OSHA #502 course. For the OSHA #501, the prerequisitecourse(s) are the OSHA #511 orOSHA #501 course, for the OSHA#503, the prerequisites are the OSHA#501 or OSHA #503 course. For the OSHA #5400, the prerequisitesare the OSHA #5410 or OSHA #5400,for the OSHA #5402 the prerequisitesare the OSHA #5400 or OSHA #5402. For the OSHA #5600, the prerequisitesare the OSHA #5600, for the OSHA#5602 the prerequisites are the OSHA#5600 or OSHA #5602.Item 10 Employer NameList your current or most recent employer.Item 11 Contact PersonList the name of your supervisor or someonein Human Resources at that employer whocan verify your employment and role for thatemployer.Item12 Contact Person’s Phone NumberList a current contact phone number for theperson identified in Item 15.Item 13 Contact Person’s Email AddressList a valid email address for the personidentified in Item 15.Item 14 Employer AddressList the current mailing address for theemployer.Item 15 Start Date of EmploymentList the date you began working for thisemployer.Item 16 End Date of EmploymentList the date you stopped working for thisemployer. If this is your current employer,list “present”.Item 17 Overall Job Duties in this PositionList the duties that you performed in thisposition, focusing on those that are safetyrelated.Item 18 Describe Safety Activities in This Position List safety related tasks performed on thejob, including the responsibility for thesafety of others.Indicate the percentage of time devoted toeach area listed below. Note: Related experience must be detailedsince this document is a record of safetyexperience and will be carefully reviewedto determine whether eligibilityrequirements have been met.Item 19 What Percentage of This Position is SafetyRelated? Indicate the percentage of time devoted tosafety related tasks in this position.Item Second Employer20-29 If needed, list the information as directed fromthe corresponding items 10-19 as applies toyour second most recent position.Page 6 of 7OSHA Form 4-50-10April 2012

OSHA Training Institute Education Centers ProgramOSHA Outreach Trainer CoursePREREQUISITE VERIFICATION FORMRead instructions before completing this form.Item Third Employer30-39 If needed, list the information as directed fromthe corresponding items 10-19 as applies toyour next most recent position. Attachadditional sheets as needed, following thesame format.Item 40a College DegreeSkip this step if you do not wish to substitutea college degree from an accrediteduniversity for 2 years work experience. Ifapplicable, place an “x” in the box indicatingyou have a college degree in safety from anaccredited university, the name of the collegeor university from which you received thedegree, the date you graduated, and thename of the degree earned. Place an “x” inthe box indicating that you have attachedyour transcripts. If you do not include a copyof your transcripts, the degree will not becounted.Item 40b Professional CertificationSkip this step if you do not if you do not wishto substitute a professional certification forwork experience. If applicable, place an “x”in the box that corresponds to theprofessional certification you currently hold.Place an “x” in the box indicating that youhave attached a copy of your professionalcertification. If you do not include proof ofyour professional certification, it will not becounted.Page 7 of 7OSHA Form 4-50-10April 2012